Marginal Cord Insertion Research Articles

Impact of Marginal and Velamentous Cord Insertion on Uterine Artery Doppler Indices, Fetal Growth, and Preeclampsia.

To assess the impact of marginal (MCI) or velamentous (VCI) cord insertion on uterine artery pulsatility index (UtA PI), preeclampsia (PE), and offspring's birthweight (BW). A retrospective cohort study of singleton pregnancies, undergoing routine anomaly scan at 20+0 -23+6 gestational weeks, was conducted between 2016 and 2020. The effect of placental cord insertion on BW and UtA mean PI z-scores was assessed using the t test or analysis of variance and post-hoc tests; their association with PE was evaluated with the chi-square test. A multivariate logistic regression model was employed to assess the independent association of placental cord insertion and UtA PI z-score with PE, BW <10th, <5th centile, and intrauterine death (IUD), using specific confounders. The study population included 4453 pregnancies. Conception via assisted reproductive technology (ART) was associated with increased risk of abnormal cord insertion (odds ratio [OR]: 2.237; 95% confidence interval [CI]: 1.561-3.206; P < .001). Women with MCI/VCI had higher mean UtA PI z-score than those with central/eccentric (0.29 vs 0.01; mean difference: -0.28; 95% CI: -0.399 to -0.165; P < .001). MCI/VCI were associated with higher rates of BW <10th centile (central/eccentric: 16.2% vs MCI: 21.9% vs VCI: 35.7%; P < .001) and BW <5th centile (9.8 vs 15.1 vs 23.2%, respectively; P < .001). No association was identified between MCI/VCI and PE (P=.968). Finally, VCI (aOR: 13.717; 95% CI: 1.576-119.379; P=.018) and increased BMI (aOR: 1.167; 95% CI: 1.071-1.271; P < .001) significantly correlated with IUD. Abnormal cord insertion is more common in ART pregnancies. MCI/VCI are associated with higher mean UtA PI and lower BW centile, but not with increased risk of PE.

Placental pathology in a pregnant woman with severe COVID-19 and successful ECMO treatment: a case report

BackgroundInfection with SARS-CoV-2 during pregnancy can lead to a severe condition in the patient, which is challenging for obstetricians and anaesthesiologists. Upon severe COVID-19 and a lack of improvement after multidrug therapy and mechanical ventilation, extracorporeal membrane oxygenation (ECMO) is introduced as the last option. Such treatment is critical in women with very preterm pregnancy when each additional day of the intrauterine stay is vital for the survival of the newborn.Case presentationWe report a case of a 38-year-old woman at 27 weeks of gestation treated with multidrug therapy and ECMO. The woman was admitted to the intensive care unit (ICU) with increasing fever, cough and dyspnoea. The course of the pregnancy was uncomplicated. She was otherwise healthy. At admission, she presented with severe dyspnoea, with oxygen saturation (SpO2) of 95% on passive oxygenation, heart rate of 145/min, and blood pressure of 145/90. After confirmation of SARS-CoV-2 infection, she received steroids, remdesivir and convalescent plasma therapy. The foetus was in good condition. No signs of an intrauterine infection were visible. Due to tachypnea of 40/min and SpO2 of 90%, the woman was intubated and mechanically ventilated. Due to circulatory failure, the prothrombotic activity of the coagulation system, further saturation worsening, and poor control of sedation, she was qualified for veno-venous ECMO. An elective caesarean section was performed at 29 weeks on ECMO treatment in the ICU. A preterm female newborn was delivered with an Apgar score of 7 and a birth weight of 1440 g. The newborn had no laboratory or clinical evidence of COVID-19. The placenta showed the following pathological changes: large subchorionic haematoma, maternal vascular malperfusion, marginal cord insertion, and chorangioma.ConclusionsThis case presents the successful use of ECMO in a pregnant woman with acute respiratory distress syndrome in the course of severe COVID-19. Further research is required to explain the aetiology of placental disorders (e.g., maternal vascular malperfusion lesions or thrombotic influence of COVID-19). ECMO treatment in pregnant women remains challenging; thus, it should be used with caution. Long-term assessment may help to evaluate the safety of the ECMO procedure in pregnant women.

Marginal umbilical cord insertions in a bipartite placenta responsible for placenta abruption: a case report

Hemorrhage is one of the major causes of maternal death. Main causes of APH are placenta previa, placenta abruption and uterine rupture. Rare causes of placenta abruption include marginal and velamentous umbilical cord insertions. We hereby present a case of placenta abruption due to marginal umbilical cord insertions occurring on a bipartite placenta. A 40-year-old nulliparous African woman, 35 weeks pregnant consulted for dark red pervaginal bleeding, which occurred recently. Past history was unremarkable. Her pregnancy was well followed up. A recent ultrasound scan revealed a fundal inserted placenta. Physical examination revealed a fundal height of 37 cm, no uterine activity, normal fetal heart tones and a blood-stained vulva. Our diagnosis was a mild placenta abruption. An obstetrical ultrasound carried out revealed a normal pregnancy and a retroplacental blood clot of 11mm. A safe baby was born through an emergency cesarean section which revealed a normally inserted bipartite placenta with a 10% placenta detachment located on one placenta half and two cords inserted marginally. The postoperative period was uneventful and she was discharged five days after cesarean section. This case report shows that marginal cord insertion, which can lead to placenta abruption, can be also observed on a bipartite placenta.

VP44.13: Prenatal ultrasound diagnosis of abnormal placental cord insertion and pregnancy outcome

Abnormal placental cord insertion includes marginal and velamentous placental cord insertion. With the development of obstetric ultrasound, such abnormal placental cord insertion can be diagnosed prenatal, and the relationship between the abnormal placental cord insertion of prenatal diagnosis and the pregnancy outcome is to be investigated. We performed a prospective study of singleton and multiple pregnancies women undergoing obstetric ultrasonography between 20–24 weeks of gestation at Ewha Women's University Hospital from February 2019 to October 2020. For the characteristics of pregnant women and pregnancy outcome, continuous variables were expressed as mean ± standard deviation and were compared using Student's t-test, or median (IQR) using Mann-Whitney test. Abnormal placental cord insertion was confirmed in 23 cases (6.42%) after a total of 358 deliveries, which 18 cases (5.02%) of marginal cord insertion were found, and 5 cases (1.40%) of velamentous placental cord insertion. Preterm birth, pre-eclampsia, fetal anomaly, postpartum hemorrhage, SGA, and LBW were significantly increased. (P-value< 0.05). Delivery by primary Caesarean section, gestational diabetes mellitus, low APGAR score was not statistically significant, but showed a tendency to increase. The results are given in table 1. Abnormal placental cord insertion is associated with poor pregnancy outcomes. Detecting abnormalities in the placenta attachment area before delivery can improve the prognosis of pregnancy. More cohort study is needed to evaluate the effects of abnormal placental cord insertion and pregnancy outcome. VP44.13: Table 1. Association of abnormal placental cord insertion with pregnancy outcome Central cord insertion (n = 335) Abnormal cord insertion (n = 23)

Maternal exposure to fine particulate matter over the first trimester and umbilical cord insertion abnormalities.

Our hypothesis was that exposure to fine particulate matter (PM2.5) is related to abnormal cord insertion, which is categorized as a form of placental implantation abnormality. We investigated the association between exposure to total PM2.5 and its chemical components over the first trimester and abnormal cord insertion, which contributes to the occurrence of adverse birth outcomes. From the Japan Perinatal Registry Network database, we used data on 83 708 women who delivered singleton births at 39 cooperating hospitals in 23 Tokyo wards (2013-2015). We collected PM2.5 on a filter and measured daily concentrations of carbon and ion components. Then, we calculated the average concentrations over the first trimester (0-13 weeks of gestation) for each woman. A multilevel logistic-regression model with the hospital as a random effect was used to estimate the odds ratios (ORs) of abnormal cord insertion. Among the 83 708 women (mean age at delivery = 33.7 years), the frequency of abnormal cord insertion was 4.5%, the median concentration [interquartile range (IQR)] of total PM2.5 was 16.1 (3.61) μg/m3 and the OR per IQR for total PM2.5 was 1.14 (95% confidence interval = 1.06-1.23). In the total PM2.5-adjusted models, total carbon, organic carbon, nitrate, ammonium and chloride were positively associated with abnormal insertion. Organic carbon was consistently, and nitrate tended to be, associated with specific types of abnormal insertion (marginal or velamentous cord insertion). Exposure to total PM2.5 and some of its components over the first trimester increased the likelihood of abnormal cord insertion.

Clinical characteristics of a novel “Type 3” vasa previa: case series at a single center

Objective Vasa previa is a condition in which fetal blood vessels are located on fetal membranes within 2 cm of the internal cervical os. Vasa previa has been classified into two types: Type 1, in which vessels connect a velamentous umbilical cord to the placenta, and Type 2, in which vessels connect the lobes of a bilobed placenta or the placenta to a succenturiate lobe. However, there are also atypical cases that cannot be classified into these two types. These cases are manifested by a center or marginal cord insertion with a normal shaped placenta, and fetal vessels were also located on membranes around the internal cervical os. These cases were recently proposed as Type 3 vasa previa. The present study investigated the incidence of Type 3 vasa previa and elucidated differences in clinical and ultrasonographical characteristics between traditional types and Type 3. Methods This was a single-center observational study using a cohort of all vasa previa cases between January 2010 and April 2020. Results Among 8,723 deliveries, there were 14 cases (0.16%) of vasa previa, all of which were diagnosed prenatally by US, not after vaginal delivery or CS. There were 9 (64%), 0, and 5 (36%) cases of Types 1, 2, and 3, respectively. All 5 Type 3 cases had only one fetal aberrant vessel of vasa previa, while 6 out of 9 Type 1 cases (67%) had two or more aberrant vessels. Seven Type 1 cases (78%) possessed two or more known risk factors, such as velamentous cord insertion, whereas all Type 3 cases only had one. Difficulties were associated with diagnosing two out of the 14 cases of vasa previa using routine transvaginal ultrasonography (TVUS). In these cases, the aberrant fetal vessel of vasa previa was only one vein with a thin wall that was not clearly visualized by gray-scale TVUS as well as slow flow that was easily misread by color-Doppler. These cases were ultimately diagnosed as vasa previa based on non-pulsatile flow detected by color and pulsed Doppler. Conclusions The present results suggest that Type 3 may account for a large proportion of vasa previa cases. Most Type 3 cases may present with only one fetal aberrant vessel of vasa previa and fewer risk factors, suggesting that the diagnosis of vasa previa may be more challenging in Type 3 cases than in the other types. Vasa previa with a venous vasa previa needs to be considered because of the difficulties associated with an antenatal diagnosis due to unclear imaging of the vasculature or the lack of specific color Doppler flow patterns. Pulsed Doppler imaging may be helpful for the diagnosis of these cases.

Abnormal umbilical cord insertions in singleton deliveries: placental histology and neonatal outcomes

AimsThis study aimed to identify any microscopic features associated with abnormal (membranous/velamentous or marginal) placental cord insertions and to analyse their adverse neonatal outcomes.MethodsWe retrospectively analysed the records—including pathological findings,...

Obstetric Outcomes in Singleton Pregnancies with Abnormal Placental Cord Insertions.

There is wide variation in the management of pregnancies complicated by abnormal placental cord insertion (PCI), which includes velamentous cord insertion (VCI) and marginal cord insertion (MCI). We tested the hypothesis that abnormal PCI is associated with small for gestational age (SGA) infants. This is a retrospective cohort study of all pregnant patients undergoing anatomic ultrasound at a single institution from 2010 to 2017. Patients with abnormal PCI were matched in a 1:2 ratio by race, parity, gestational age at the time of ultrasound, and obesity to patients with normal PCIs. The primary outcome was SGA at delivery. Secondary outcomes were cesarean delivery, preterm delivery, cesarean delivery for nonreassuring fetal status, 5-minute Apgar score < 7, umbilical artery pH < 7.1, and neonatal intensive care unit admission. These outcomes were compared using univariate and bivariate analyses. Abnormal PCI was associated with an increased risk of SGA (relative risk [RR]: 2.43; 95% confidence interval [CI]: 1.26-4.69), increased risk of preterm delivery <37 weeks (RR: 3.60; 95% CI: 1.74-7.46), and <34 weeks (RR: 3.50; 95% CI: 1.05-11.63) compared with patients with normal PCI. There was no difference in rates of cesarean delivery, Apgar score of <7 at 5 minutes, acidemia, or neonatal intensive care unit admission between normal and abnormal PCI groups. In a stratified analysis, the association between abnormal PCI and SGA did not differ by the type of abnormal PCI (p for interaction = 0.46). Abnormal PCI is associated with an increased risk of SGA and preterm delivery. These results suggest that serial fetal growth assessments in this population may be warranted. · Abnormal PCI is associated with SGA infants and preterm birth.. · If an abnormal PCI is identified, the provider should consider serial growth ultrasounds.. · There is no difference in obstetric outcomes between VCI and MCI..

Marginal cord insertion among singleton births at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

BackgroundUmbilical cord may insert abnormally i.e. marginal insertion to a placenta which can cause different birth and perinatal complications. Despite the increased effort taken by different responsible bodies, the prevalence of birth and perinatal complications are still high, possibly due to anomalous cord insertion. So far, anomalous cord insertion lacks proper attention in different medical settings. Hence, the present study aims to assess the magnitude, risk factors, and adverse birth outcomes of marginal cord insertion among singleton births.MethodsAn institution-based cross-sectional study design was conducted. A systematic random sampling technique was used to select study participants. Data were collected by using a structured questionnaire and it was entered into epi-data version 3.1 then exported to SPSS version 20 for data cleansing and analysis. Bi-variable and multivariable logistic regressions were employed to identify risk factors and adverse outcomes associated with marginal cord insertions. Crude and adjusted odds ratio (P-value < 0.05) with a 95% confidence interval were calculated.ResultThe magnitude of marginal cord insertion was 6.4% (95% CI = 4.4–8.8%) in singleton pregnancies. Independent risk factors for marginal cord insertion were advanced maternal age (AOR = 2.24, 95% CI: 1.35–11.08), primiparity (AOR = 1.98, 95% CI: 1.37–8.69), maternal chronic hypertension (AOR = 3.07, 95% CI: 1.66–9.76), previous cesarean delivery (AOR = 2.51, 95% CI: 1.43–10.21), and use of intrauterine contraceptive device before pregnancy (AOR = 2.22, 95% CI: 1.36–12.30). Pregnancies complicated by marginal cord insertion are at higher risk to develop low birth weight (AOR = 2.89, 95% CI: 1.23–6.80), preterm birth (AOR = 4.00, 95% CI: 1.44–11.14), and emergency cesarean delivery (AOR = 3.68, 95% CI: 1.03–13.81).Conclusion and recommendationMarginal cord insertion is a mistreated potential risk for low birth weight, preterm birth, and emergency cesarean delivery. Routine screening of marginal cord insertion should be considered in pregnancies with advanced age, nulliparity, hypertensive disorder, history of cesarean section, and intrauterine contraceptive device usage before pregnancy.

A Study Evaluating Correlation between Umbilical Cord Attachment on Placenta in Normotensive and Hypertensive Pregnant Females and its Effects on Fetus

Introduction: Well nourished newborn is a reflection of adequate placental function.The umbilical cordthat connects fetus and placenta can attach itself to placenta at different placenta.The incidence of central,eccentric, marginal and velamentous cord insertion is 18%,73%, 7% and 1-2%, respectively. This insertiontype significantly influences fetal growth and pregnancy outcomes.Methodology: This study was conducted in Department of Anatomy of SBKS MIRC, Vadodara. This was acomparative study between normotensive and hypertensive group in which 500 subjects, in each group wereincluded. Insertion of umbilical cord on placentawas determined and fetal growth and outcome with type ofinsertion were correlated.Results: The two groups were comparable in terms of demographics.Higher proportion of those inhypertensive group had marginal insertion of umbilical cord (23.40%) as compared to 2.90% in normotensivegroup. Mean systolic (150.10±7.51mmHg) as well as diastolic blood pressure (91.23±4.00mmHg) washigher in those with marginal insertion of placenta. Mean fetal birth weight and APGAR score at birth and 5minute and proportion of fetus reaching full term, live births were low in those in those in the hypertensivegroup especially in those with marginal insertion of placenta.Conclusion: Thus it can be concluded that abnormal attachment of umbilical cord on placenta has significantimpact on fetal growth and influences the outcomes of pregnancy directly and indirectly

Exploring the impact of HIV infection and antiretroviral therapy on placenta morphology

IntroductionWomen living with HIV experience more adverse birth outcomes; the mechanisms are not fully understood. We examined placenta morphology and associations with birth outcomes in a Canadian cohort of women living with HIV (HIV+) on antiretroviral therapy (ART) from conception and HIV-uninfected (HIV−) women. MethodsTerm placentas from 94 women (40 HIV−, 54 HIV+) were studied. Trimmed placenta weight was collected. Placenta digital photos were used to compute morphometric parameters. Regression models investigated associations between log-transformed placenta parameters and birth outcomes. ResultsWe observed a trend towards lower placenta weight and smaller placenta area in the HIV+ group, both of which were significantly associated with small for gestational age births. HIV+ serostatus was associated with 6-fold (95%CI 2–20) greater odds of having placenta area in the lowest quartile (<236 cm2). Cord marginality (distance from the edge) was significantly lower in the HIV+ group (p = 0.004), with 35% of placenta having an abnormal (marginal or velamentous) cord insertion vs. 12.5% in the HIV− group (p = 0.01). Velamentous cord insertion was seen in 13% of placentas in the HIV+ vs. 0% in HIV− group (p = 0.02). A significant correlation between cord marginality and placenta thickness was observed in the HIV− group, with a more marginal cord being associated with a thicker placenta. This correlation was not observed in the HIV+ group. HIV+ placentas exposed to protease inhibitors were significantly less circular compared to the HIV− group (p = 0.03). ConclusionOur data suggest that HIV/ART exposure affects placenta morphology and is associated with higher rates of abnormal cord insertion.

Measurement of Marginal Placental Cord Insertion by Prenatal Ultrasound Was Found Not to Be Predictive of Adverse Perinatal Outcomes

ObjectivesThe clinical importance of marginal cord insertion (MCI) is currently controversial. In this study, we examined the association between MCI and adverse perinatal outcomes. We also evaluated the ultrasound‐measured distance from the site of placental cord insertion (PCI) to the placental margin (PCI distance) and perinatal outcomes.MethodsThis was a retrospective cohort study of MCI and control pregnancies presenting to a single institution between September 2014 and August 2016. Marginal cord insertion was diagnosed on routine anatomy ultrasound scans at 20 weeks’ gestation. The primary outcome was fetal intolerance to labor. Secondary outcomes of interest included mode of delivery, gestational age at delivery, Apgar scores at 1 and 5 minutes, birth weight, delivery complications, and neonatal intensive care unit admission. The PCI distance was determined by an ultrasound review. Statistical significance was evaluated by a χ2 analysis, descriptive statistics, Wilcoxon tests, and regression models with log‐transformed outcomes, the PCI distance, or both as needed.ResultsOf 675 abnormal cord insertion cases, we identified 183 that met inclusion criteria. We found no statistically significant association between MCI and fetal intolerance to labor (odds ratio, 1.24 [95% confidence interval, 0.55–2.80]; P = .71) or secondary outcomes. Furthermore, we found no significant correlation between perinatal outcomes and the PCI distance.ConclusionsOur study suggests that MCI pregnancies, regardless of the specific PCI distance, might not be at increased risk of adverse perinatal outcomes. This finding questions the need for heightened antepartum surveillance of this patient population.

Sonographic Diagnosis of Velamentous and Marginal Placental Cord Insertion.

Routine second trimester ultrasound (US) examinations include an assessment of the umbilical cord given its vital role as a vascular conduit between the maternal placenta and fetus during fetal development. Placental cord insertion abnormalities can be identified during prenatal US screening and are increasingly recognized as independent risk factors for various complications during pregnancy and delivery. The purpose of this pictorial review is to illustrate examples of velamentous and marginal placental cord insertion with an emphasis on how to differentiate their morphology using color Doppler US.

Assisted reproductive technologies (ART) and placental abnormalities.

Objectives Assisted reproductive technologies (ART) may be associated with placental abnormalities including placenta previa, umbilical cord abnormalities, and placental abruption. Our study evaluates the relationship between ART and placental abnormalities compared with spontaneously conceived controls. Methods An IRB-approved cohort study was conducted including women who delivered between January 2013 and December 2018. We excluded delivery prior to 23weeks and known fetal anomalies. Patients were matched with controls (2:1) for parity, age, and mode of delivery. Controls were women who had spontaneously conceived and delivered immediately preceding and following the index delivery. The primary outcome was placental abnormalities found on both antenatal ultrasound and pathology in ART gestations compared with spontaneously conceived gestations. Results There were 120 ART pregnancies and 240 matched control pregnancies identified. The groups were similar for parity, BMI, comorbidities, number of multiples, mode of delivery, and female newborns. The ART group had a higher maternal age (37.1±5y vs. 30.0±5y; p<0.001), greater preterm birth (29 vs. 6%; p<0.001), and lower BW (2,928±803g vs. 3,273±586g; p<0.001). The ART group had a higher incidence of placenta previa on ultrasound (4.0 vs. 0.4%, p=0.01), adherent placentas at delivery (3 vs. 0% p=0.014), placental abruption (2 vs. 0%; p=0.04), as well asan increased rate of velamentous cord insertion (12 vs. 3%, p<0.001) and marginal cord insertion (28 vs. 15%, p=0.002). ART demonstrated a two-fold likelihood of abnormal placental pathology. Conclusions ART is associated with increased rate of placental abnormalities, including abnormal umbilical cord insertion and increased rates of adherent placentation. This information may be beneficial in planning and surveillance in patients with ART pregnancies.

Is Preimplantation Genetic Testing Associated with Increased Risk of Abnormal Placentation After Frozen Embryo Transfer?

This study aimed to assess the association of preimplantation genetic testing (PGT) with abnormal placentation among a cohort of pregnancies conceived after frozen embryo transfer (FET). This is a retrospective cohort study of women who conceived via FET at the University of California, San Francisco from 2012 to 2016 with resultant delivery at the same institution. The primary outcome was abnormal placentation, including placenta accreta, retained placenta, abruption, placenta previa, vasa previa, marginal or velamentous cord insertion, circumvallate placenta, circummarginate placenta, placenta membranacea, bipartite placenta, and placenta succenturiata. Diagnosis was confirmed by reviewing imaging, delivery, and pathology reports. Our secondary outcome was hypertensive disease of pregnancy. A total of 311 pregnancies were included in analysis; 158 (50.8%) underwent PGT. Baseline demographic characteristics were similar between groups except for age at conception and infertility diagnosis. Women with PGT were more likely to undergo single embryo transfer (82.3 vs. 64.1%, p < 0.001). There were no statistically significant differences in the rate of the primary outcome (26.6 vs. 27.4%, p = 0.86) or hypertensive disorders of pregnancy (33.5 vs. 33.3%, p = 0.97), which remained true after multivariate analysis was performed. Among pregnancies conceived after FET, PGT is not associated with a statistically significant increased risk of abnormal placentation or hypertensive disorders of pregnancy. · In pregnancies conceived by FET, PGT is not associated with increased risk of abnormal placentation.. · In pregnancies conceived by FET, PGT is not associated with increased risk of hypertensive disorders.. · Differences in outcomes of PGT pregnancies may be related to FET rather than trophectoderm biopsy..

Curettage is a risk factor for marginal umbilical cord insertion

Curettage is a risk factor for marginal umbilical cord insertion

Placental vascular tree characterization based on ex-vivo MRI with a potential application for placental insufficiency assessment

IntroductionUnderstanding regarding the whole placental vascular network structure is limited. Our aim was to quantitatively characterize the human placental vascular tree ex-vivo using high-resolution MRI. Methods34 normal placentas were rinsed and injected with a solution of gelatin and contrast agent through the umbilical vessels. A sample of six placentas taken from pregnancies with intrauterine-growth-restriction (IUGR) was used to demonstrate the potential application to cases with placental insufficiency. Structural ex-vivo MR scans of the placenta were performed using high resolution T1 weighted images. A semi-automatic method was developed to segment and characterize the placental vascular architecture: placental volume and cord insertion location, number of bifurcations, generations and vessels diameters. ResultsDifferent vascular patterns were found in placentas with central versus marginal cord-insertion. Based on the placental volume and number of bifurcations we were able to predict birth weight. Furthermore, preliminary results on IUGR sample demonstrated the potential of this method to differentiate between small newborns with suspected IUGR from small normal newborns who reached their full growth potential. Results obtained using the automatic method were validated against manual values demonstrating no significant differences or bias. Histopathology supported the imaging findings. DiscussionThis is the first study to quantitatively characterize the human placental vascular architecture using high resolution ex-vivo MRI. Different patterns of vascular architecture may be related to different functioning of the placenta and affect fetal development. This method is simple, relatively fast, provides detailed information of the placental vascular architecture, and may have important clinical applications.

Marginal placental cord insertion: the need for follow up?

Objective The objectives of this study were (1) to estimate the association between marginal placental cord insertion (PCI) and small for gestational age (SGA) and other adverse perinatal outcomes and (2) to determine if pregnancy-associated plasma protein A (PAPP-A) levels was altered in these patients. Methods It was a retrospective cohort study of singleton pregnancies undergoing ultrasound between 2016 and 2018. Marginal PCI was defined as a distance of ≤2 cm from placental edge to PCI site, visualized in both sagittal and transverse planes, and diagnosed between 16 and 32 weeks. Velamentous PCI were excluded. The primary outcome was SGA, defined as birthweight below 10th percentile for gestational age. Pregnancies with marginal PCI were compared to those with normal PCI with respect to maternal characteristics, PAPP-A levels and adverse perinatal and delivery outcomes. Results The incidence of marginal PCI was 4.2% (76/1819). Compared to those with a normal PCI, patients with a marginal PCI were more likely to be nulliparous and less likely to be African American or morbidly obese (p < .05). SGA rate was similar between the groups (17.6% vs. 18.1%). There was a trend toward an increased incidence of oligohydramnios, polyhydramnios and breech presentation in patients with marginal PCI; however, these did not reach statistical significance. The incidence of low PAPP-A level was comparable between the groups (18.4% vs. 14.3%, p > .05). Conclusion Our study did not demonstrate any increase in adverse pregnancy outcomes in the presence of marginal PCI. These findings may provide reassurance for counseling patients with this sonographic finding.

In Search of Placenta and Umbilical Cord Risk Factors for Fetomaternal Hemorrhage: A Case-Control Study [18O

INTRODUCTION: Fetomaternal hemorrhage (FMH) is an obstetric complication associated with adverse fetal and neonatal outcomes. Few reliable risk factors other than maternal trauma have been identified. Previous research has suggested an association between potentially obstructive umbilical cord abnormalities and FMH. METHODS: We conducted an IRB-approved case-control study within Kaiser Permanente Northern California between January 2008 and December 2017 to investigate whether cord abnormalities were associated with FMH. Cases were defined by adverse fetal or neonatal outcomes related to hypovolemia in the setting of a positive maternal flow cytometry for fetal hemoglobin. Controls were selected based on a negative flow result at time of delivery and available placental pathology report for review, matched to gestational age and year of delivery of cases. Delivery records and pathology reports were analyzed for 56 cases and 132 controls. RESULTS: There was at least one cord abnormality for 23.2% of cases and 25.8% of controls (P=.71). There were no significant differences between the two groups in placental weight percentile, cord length, or cord diameter. Marginal and velamentous cord insertion occurred slightly more frequently in controls compared to cases. Cord hypercoiling was found in 7.1% of cases vs 5.3% of controls (P=.74). CONCLUSION: We did not identify gross placental or cord characteristics associated with FMH. However, case numbers were too small for statistical significance and our study was limited to placentas sent to pathology, which may have biased our control group towards cord lesions. Further research is required to identify whether an association exists between cord abnormalities and FMH.

Antenatal Diagnosis of Marginal and Velamentous Placental Cord Insertion and Pregnancy Outcomes

To evaluate the association between antenatal diagnosis of velamentous and marginal placental cord insertions with adverse perinatal outcomes of small-for-gestational-age (SGA) birth weight (less than the 5th percentile), caesarean birth, and perinatal mortality. Using a diagnostic imaging database, we performed a cohort study of all consecutive singleton pregnancies (35,391), including 1,427 cases of marginal and 107 cases of velamentous cord insertion, delivered after 24 6/7 weeks of gestation between January 1, 2012, and December 31, 2015, at a single Canadian tertiary care center. Cases with placenta previa, vasa previa, no documented cord insertion, or fetal anomalies were excluded. In the overall cohort, the rate of birth weight less than the 5th percentile was 5.2%, the rate of cesarean delivery was 27.1%, and the rate of perinatal mortality was 0.24%. Velamentous cord insertion was associated with SGA (relative risk [RR] 2.19, 95% CI 1.28-3.74). This persisted after controlling for smoking during pregnancy, diabetes, and hypertension (adjusted odds ratio [aOR] 1.98, 95% CI 1.03-3.84). Velamentous cord insertion was also associated with an increased risk of caesarean birth (RR=1.38, 95% CI=1.08-1,77) and perinatal death (1.87%, RR 8.15, 95% CI 2.02-32.8), a relationship that persisted after controlling for smoking during pregnancy, diabetes, and hypertension (aOR 1.53, 95% CI 1.01-2.32). Marginal cord insertion was not associated with birth weight less than the 5th percentile (RR 1.23, 95% CI 1.00-1.51), cesarean delivery (RR 1.01, 95% CI 0.92-1.10), or perinatal death (RR 1.53, 95% CI 0.62-3.78). Antenatal diagnosis of velamentous placental cord insertion is associated with birth weight less than the 5th percentile.